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We reviewed 103 controlled clinical trials that compared the antiarthritic efficacy and tolerance of previously and currently marketed nonsteroidal antiinflammatory drugs (NSAIDs) and aspirin. Of 52 studies, 35 had data sufficient to calculate an NSAID efficacy index (the ratio of mean improvement in NSAID-treated patients to that in aspirin-treated patients) based on subjective and/or objective criteria. The mean indexes (obtained from all studies from which an index could be calculated) indicated no statistically significant difference in efficacy between aspirin and the NSAIDs as a group; the indexes tended to become less variable as the number of study subjects increased. Tolerance, assessed from the percentage of patients who discontinued the drug because of side effects, was significantly greater for NSAIDs than for aspirin. The NSAIDs had greater efficacy but not greater toxicity at increased doses. Efficacy differences described among NSAIDs in some studies were attributable either to comparisons at nonequivalent doses or to chance.

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To determine the reliability of the laboratory in detecting drugs taken by overdosed patients, we evaluated laboratory performance on an unbiased sample of actual clinical specimens. Replicate serum and urine samples from a series of 20 consecutive clinically overdosed patients were sent to three commercial laboratories and one academic research laboratory for identification and quantification of intoxicating agents. All laboratories used the advance analytical techniques of gas chromatography-mass spectrometry. The results suggest that laboratories do not reliably identify drugs in the serum of overdosed patients, partly because of technical limitation, partly because of laboratory error, and possibly because of inadequate specimens. Drugs judged responsible for the overdose were identified in only 50% to 70% of the cases, depending on the laboratory. Reported concentrations sometimes varied over a 10-fold range.

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The effect of dietary fiber on digoxin absorption was investigated in 12 patients taking digoxin. Steady-state serum digoxin concentrations were determined while subjects were on a regular diet and while they were on a diet supplemented with 22 gm bran daily. During the period of bran supplementation, the serum digoxin concentration did not change (average change, +0.5%; 90% confidence interval, -12% to +14%). Bran does not cause a clinically significant reduction in digoxin absorption.

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An association of the histidine auxotroph of Salmonella typhimurium (strain TA1538) within the gastrointestinal tract of otherwise germ-free Sprague-Dawley rats is maintained during observations for up to 7 months. The bacteria exceed concentrations of 10(7)/g in the forestomach and exceed concentrations of 10(8)/g in the lower bowel and feces. When carcinogens are ingested, the number of revertants in the feces increases. The ingestion of structurally related compounds which are not mutagenic to the bacteria in vitro and for which no evidence of carcinogenicity exists does not increase the number of revertants in the feces. The numbers of salmonella are increased by the addition of Lactobacillus plantarum and Bacteroides fragilis but the salmonella disappear from the gastrointestinal tract when the rats are conventionalized. With the additional flora, there is a decrease in the number of revertants appearing in the feces in response to a given dose of carcinogen. This decrease may reflect an effect of the flora on the activity of the metabolic pathway responsible for the presence of the ultimate carcinogen or it may simply be an effect on the salmonella mutants themselves.

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A histidine auxotroph of Salmonella typhimurium, strain TA1538, will lodge for several months in the gastrointestinal tract of otherwise germ-free rats and of rats additionally associated with bacteria characteristic of the normal flora such as Lactobacillus plantarum and Bacteroides vulgatus. In the presence of the additional flora, the concentration of strain TA1538 is diminished in the stomach but not in the lower gastrointestinal tract or in the feces. Following the ingestion of 2-nitrofluorene, there is an increase in the concentration of revertants in the feces which reflects that observed in the colon and cecum. A dose-response relationship can be demonstrated between the amount of 2-nitrofluorene ingested and the concentration of revertants in the feces. A given dose of 2-nitrofluorene, however, produces fewer revertants in the feces of rats with the additional flora than in the feces of rats associated only with strain TA1538. It is not clear whether the decreased number of revertants in the feces in the presence of the additional flora is a result of metabolic transformations of 2-nitrofluorene by B. vulgatus, which can be demonstrated in vitro, or a result of the displacement of strain TA1538 from the stomach. The rat associated with strain TA1538, or other Ames tester strains, may be useful for detecting carcinogens as mutagens within the gastrointestinal tract and for determining the influence of various constituents of the bacterial flora on the concentration of mutagenic compounds.

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Salmonella typhimurium strain TA1538 described by Ames, in association with otherwise germ-free rats, colonizes the gastrointestinal tract. The revertants enumerated in the feces of each of these rats varies in a coordinated manner in relation to the day on which the measurement is made. In response to the oral ingestion of a single dose of 2-nitrofluorene, the concentration of revertants in the feces increases and then returns essentially to control values within 6 days. When these rats are challenged repeatedly with a similar oral dose of 2-nitrofluorene the revertent concentration in the feces remains elevated for a progressively longer time. A change in phenotype of strain TA1538 during prolonged association rather than a change in the biology of the rat seems to explain this phenomenon. Firstly, germ-free rats exposed repeatedly to 2-nitrofluorene and then associated with strain TA1538 do not have the prolonged response characteristic of multiple challenges with 2-nitrofluorene. Secondly, strain TA1538 reisolated after several weeks of association with the otherwise germ-free rat shows other alterations such as decreased sensitivity to 2-nitrofluorene in the pour plate assay and a decreased sensitivity to crystal violet. In spite of limitations imposed by these alterations in strain TA1538, it is possible to demonstrate a dose-response relationship between the amount of 2-nitrofluorene ingested and the concentration of revertants in the feces of exposed rats.

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The frequency of electrocardiographic evidence of coronary heart disease (CHD) and the rate of autopsy-proved myocardial infarction were determined in the Pima, a tribe of American Indians with a high prevalence of diabetes mellitus. The electrocardiograms of 701 Pimas, aged 40 years and over (85 per cent of the adult reservation population, 45 per cent of whom had diabetes) were read according to the Minnesota Code, and 120 postmortem examinations were reviewed for evidence of myocardial infarction. The frequency of CHD as evidenced by major Q-wave changes in the Pima (1.6/100) was about one-half that found in Tecumseh, Michigan (p less than 0.10). The relatively low rate of myocardial infarction at autopsy (15 per cent of males and 8 per cent of females aged 40 years and over) was consistent with the low prevalence of Q-wave changes. The subjects with diabetes had a higher rate of CHD than nondiabetics, both electrocardiographically and at postmortem examination, although the differences were not statistically significant. The low prevalence of CHD in the living Pima and the low rate of infarction at autopsy indicate that this tribe has a low frequency of CHD despite the extraordinarily high prevalence of diabetes mellitus.

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We propose that an investigation of the serum digitalis concentration as a test for digitalis toxicity should (1) study patients with similar toxic manifestations, (2) obtain control concentrations from nontoxic patients with symptoms suggesting toxicity, (3) define criteria for toxicity and nontoxicity, (4) select representative patients, (5) describe the study population and (6) analyze how much diagnostic information the serum digitalis concentration provides that cannot be inferred from other observations. To determine if available evidence validates the digitalis concentration as a test for toxicity 27 reports were reviewed. No investigation employed symptomatic controls. Of five studies most consistent with points 1-5 only three demonstrated higher mean serum digitalis concentrations in toxic patients. Whether knowledge of the digitalis concentrations was diagnostically more useful than knowledge of the digitalis dosage, renal function, serum potassium concentration and cardiac status was not determined in any study. The usefulness of the serum digitalis concentration as a test for digitalis toxicity is therefore not established.

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